socio – cultural dimensions of reproductive health...
TRANSCRIPT
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CHAPTER – 6
SOCIO – CULTURAL DIMENSIONS OF
REPRODUCTIVE HEALTH CARE
Factors in reproductive health care
In this chapter, we are examining the different socio-cultural factors
that are significantly associated with reproductive health care behavior during
ante-natal, natal and post natal periods. The variables we have identified for
analysis are: Determinants/components of antenatal care, place of antenatal
and natal care, nature of ante natal care, delivery care and post delivery
health care. On natal care, we have examined the place of delivery, type of
delivery and problems related to childbirth. These are then related to the
respondents’ current age, age at marriage, education, occupation, income and
religion. Where found relevant, the husband’s socio-economic status also has
been taken into account because on most matters relating to a woman,
especially on sexual matters the husband plays a critical role.
Accordingly, we have put forward; the following hypothesis for
testing and verification. There is significant relationship between socio
cultural background and behaviour relating to reproductive health care. For
testing purposes, reproductive health care has been divided into different
elements and then they are related to the various socio cultural variables.
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The health care awareness of any community is dependent mainly on
two factors (1) educational development, and (2) availability of health care
services/facilities and medicines. As development proceeds, this is bound to
increase over time. The expansion of medical care has contributed to the
increasing health expectations of the population through improved
accessibility and increasing their belief in modern medicine (Dileep and Ram,
2000). Safe motherhood is a part of an essential package of reproductive and
child health services. Death related to pregnancy and childbirth is the most
direct indicator of reproductive health care. But mortality statistics tell us only
a part of the story. For every woman who dies, many more suffer from serious
illness (Pachauri, 1998). By some estimates, better care during labor and
delivery could prevent 50-80 percent of maternal deaths. If obstetric
complications are handled effectively, mortality can be substantially reduced
(Pachauri, 1999).
Adequate utilization of health care services during pregnancy and
delivery ensures a healthy mother. This may imply how much reproductive
health care a women gets. In this chapter the health care received by the
respondents with respect to their reproductive health is discussed with respect
to their anti-natal and natal care. These are then examined in terms of their
socio cultural background to find out to what extent these are related.
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Ante natal care (ANC)
In any country, the number of women who receive antenatal care
(ANC) is an important indicator of women’s status. Ante Natal Care (ANC)
refers to the health needs of women during the time of pregnancy which
begins at the time of conception. ANC attendance has the strongest direct and
significant influence on the health and reproductive behavior of mothers
including safe delivery and survival conditions of children. Higher levels of
health care use are associated with better reproductive health outcomes
(Obermeyer and Palter, 1991).
It is expected that a woman who lives in a community with high access
to health resources is more likely to utilize ante-natal care services relative to
women living in communities with less access (Ogunjuyegbe and Ebigbola,
1996). Accordingly, in this study awareness and utilization of maternal health
care services are highlighted based on the information gathered from the
respondents. The information on the Auxiliary Nurse and Midwife (ANM)
and the utilization of other health care measures available to women during
pregnancy were also examined from the available data. In our society the
prevailing attitude towards pregnancy is that it is considered as a condition
that requires special treatment. Therefore ANC and medical care during
childbirth are considered essential components of pregnancy.
In the government’s rural health setup, the ANM is the health
functionary closest to the community. The ANM deals with all aspects of
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health and family welfare. In our sample 88 percent of the respondents had
visited doctors during pregnancy period and in which 68 percent had monthly
visit. They had built close communication links with the ANMs.
Whatever is the advice or knowledge they had the actual effect comes
when it becomes practical. So it is more important to look into the nature of
the check-up they had received.
It is significant to identify the components from the anti natal care
(ANC) package used by a pregnant woman for understanding the factors
behind the variations in their reproductive health status as a mother. Weight
was taken during pregnancy for more than three-fourth of the mothers (67. %)
and blood pressure was measured for a higher percentage of them (88%).
Majority of the respondents had taken folic acid tablets (66.7%) and iron
tablets (69.3%) during their pregnancy period. All pregnant women are
expected to consume at least 100 IFA tablets during their pregnancy. In our
sample it was only 6.3 percent of women who had not taken iron tablet and
6.3 percent of women had not taken folic acid tablets. Also there is variation
in the consumption of these tablets.
An important component of ANC (Ante Natal Care) is to ensure that
pregnant women are adequately protected against tetanus. Usually a pregnant
woman will have to receive two doses of tetanus toxoid. In our sample about
92.7 percent of women had taken tetanus injections. Abdominal check-ups
were done to most of the women.
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Socio-cultural determinants of ante natal care (ANC)
If pregnant women receive adequate and timely ante-natal care during
pregnancy, maternal mortality as well as morbidity can be reduced to a great
extent. The major determining factors that promote or hinder antenatal care of
rural women are social and cultural in character. In the rural areas PHC’s are
the major providers of health care because of the referral system existing in
the health sector. But the problem in the government health sector is the
inadequacy of infrastructure facilities and health care providers. At the same
time the private health care sector which is well equipped with all facilities
are very expensive as far as the rural women are concerned. Hence in several
cases, income disparity forces rural women to ignore their own health and use
available resources for treating their family members especially their husband
and children. Of course this is partly because of the socio-cultural values that
women’s requirements should have the last priority in any allocation of scarce
resources. Hence in our study an attempt has been made to examine the
utilization of maternal health services by focusing on their social and cultural
background. ANC coverage and type of ANC received during pregnancy by
selected background characteristics of women, number of ante-natal care
visits, treatments and medical checkups received during pregnancy period
assume importance in reproductive health.
In spite of the vast health infrastructure, very few rural women
received even the minimum care during pregnancy. Anemia goes undetected
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and untreated, even though government has an anemia prophylaxis
programme, according to which all pregnant women are supposed to receive
iron and folic acid tablets for about three months which are supplied to them
free of cost through Anganwadis, PHC’s and sub centers.
The main objective of pre-natal care is to ensure that the women
maintains good health throughout their pregnancy and delivers a safe and
healthy live child. To achieve these objectives the pregnant mother should be
seen by a doctor early in pregnancy and in the absence of complications, at
specified periods throughout her pregnancy and delivery (Mudaliar and
Menon, 1998).
Table: 6.1. Religion and number of ANC visits
No. of ANC
visits
Religion
monthly
visit
After 6th
month
onwards
After 8th
month
onwards
At the
time of
delivery
Total
Hindu 53
79.1%
4
6.0%
6
9.0%
4
6.0%
67
100.0%
Muslim 135
73.0%
8
4.3%
32
17.3%
10
5.4%
185
100.0%
Christian 32
66.7%
6
12.5%
7
14.6%
3
6.3%
48
100.0%
Total 220
73.3%
18
6.0%
45
15.0%
17
5.7%
300
100.0%
The appropriate timing of the ANC visits and regular attendance are
essential for optimum benefits of health care facilities. Delayed use may
reduce the effectiveness of ANC as a device to avoid pregnancy related
complications. Generally, the obstetricians recommended ANC visits to be
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made on a monthly basis up to 28th
week, fortnightly up to 36th
week and
weekly until 40th
week (NCPD, Kenya, 1999).
When the Antenatal care visits of the respondents were analyzed with
their religion (Table 6.1) it was found that the vast majority of the Hindu
respondents (79.1%) had undertaken monthly visits during their pregnancy
period. They were closely followed by Muslims (73%). At the same time this
was only 66.7 percent in the case of Christian respondents. Frequent ANC
visits enable the doctor to detect the pregnancy related problems at an early
stage and can control the problem through medication. In this matter clear
religious difference is perceptible.
Table: 6.2. Education and number of ANC visits
No. of ANC visits
Education
monthly
visit
After 6th
month
onwards
After 8th
month
onwards
At the
time of
delivery
Total
Illiterate 12
54.5%
2
9.1%
5
22.7%
3
13.6%
22
100.0%
semi literates 47
51.1%
11
12.0%
22
23.9%
12
13.0%
92
100.0%
High School 134
84.3%
5
3.1%
18
11.3%
2
1.3%
159
100.0%
Higher Secondary 19
100.0%
0
.0%
0
.0%
0
.0%
19
100.0%
Graduate 7
100.0%
0
.0%
0
.0%
0
.0%
7
100.0%
Post Graduate 1
100.0%
0
.0%
0
.0%
0
.0%
1
100.0%
Total 220
73.3%
18
6.0%
45
15.0%
17
5.7%
300
100.0%
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Table 6.2 reveals that a vast majority (73.3%) of the respondents had
undertaken monthly ANC visits while 5.7 percent had visited health centers
only during delivery time. But when we examine the data in terms of the level
of education of the respondents we will find that there is a close relationship
between the level of education and monthly visits which are the requirements
for good reproductive health. The use of this facility increases progressively
with the rise in educational level. Among the higher secondary, graduate and
post graduate respondents the use was 100% while this was 54.5 percent
among illiterates and 51.1 percent among semi literates. It was also noticed
that among the respondents who had undertaken ANC visit only at the time of
delivery 13.6 percent were illiterate and 13 percent were semi literates and
none from the higher educated groups. From this analysis it can be concluded
that as the level of education increases monthly ANC visits also increases.
This shows that the increased level of education increases their need for
undertaking ANC visits, which in turn increased their positive attitude
towards ANC visits. Education in ANC is an essential element in good health
practice. If pregnant women do not conduct visits to the ante natal care
centers from the beginning of pregnancy, it will be difficult for the care givers
to identify and keep track of the health problems and this may result in
gynecological morbidity and risky delivery.
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Table: 6.3. Income and number of ANC visits
No. of ANC
visits
Income
monthly
visit
After 6th
month
onwards
After 8th
month
onwards
At the
time of
delivery
Total
Below Rs.1000 54
57.4%
11
11.7%
18
19.1%
11
11.7%
94
100.0%
Rs.1001-5000 102
75.6%
6
4.4%
22
16.3%
5
3.7%
135
100.0%
Rs. 5001-10000 34
85.0%
1
2.5%
4
10.0%
1
2.5%
40
100.0%
Above 10,000 30
96.8%
0
.0%
1
3.2%
0
.0%
31
100.0%
Total 220
73.3%
18
6.0%
45
15.0%
17
5.7%
300
100.0%
To find out whether economic background of the respondents has a
role to play in the frequency of their ANC visits the data was cross tabulated
with the frequency of visits. Table 5.4 gives details. The analysis showed that
a vast majority of the respondents (85%) in the income group of Rs.5001-
10,000 and 96.8 percent in the above Rs. 10,000 income group paid monthly
visits during pregnancy period while only 19.1% in the low income group of
below Rs. 1000 and 16.3% in the Rs. 100 –5000 income group had visited
ANC centers only after 6 months of their pregnancy. Thus when income level
is considered, it is found that high income group women visited more often
and earlier than the low income group women. In fact as in the case of
education, there is also a steady increase in the case of monthly visits to PHCs
as income increases. This may be due to the fact that respondents being poor
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avoided or postponed their visits to the PHC. They were also afraid that they
will have to spend more money on medicines and checkups if they meet the
doctors. This reveals that as the income increases their tendency to visit health
care centers early also increases
The calculated value of chi-square at 9 degrees of freedom is 32.23,
which is higher than the expected value of chi square at probability 0.2.
Therefore we can reject the null hypothesis and conclude that there is
significant relationship between the income of the respondent and the pre-
natal visit of the respondent.
We may conclude this section by saying that there is close relationship
between religion, education and income on the one hand and availing to ANC
services from the very first month of pregnancy, as is intended.
Components of Ante Natal Care (ANC)
The components of ANC during pregnancy period include medical
treatment like tetanus injection, oral supplement of iron, folic-acid and
vitamin tablets, awareness building through advices regarding type of food
intake as well as medical check-ups which include checking of blood
pressure, height and weight, testing of urine and blood, internal check-ups,
etc.
In order to understand to what extent the respondents had undergone
these treatments during their pregnancy period and to what extent the social
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and cultural factors are involved in availing such facilities from the health
care centers, the following tables were prepared. (Tables 6.4, and 6.5)
Table: 6.4. Income and medical treatment availed during pregnancy period
during pregnancy
period
Income
taken
tetanus
injection
Iron
supplement
Folic acid
supplement
Vitamin
supplement
Below 1000 87.1% 78.9% 76.0% 85.7%
1001-5000 96.3% 95.3% 95.2% 96.3%
5001-10000 97.4% 97.0% 97.1% 97.3%
Above 10,000 96.8% 96.8% 96.8% 96.8%
During pregnancy period women must take two tetanus injections. She
should also consume iron, folic acid and vitamin supplements throughout her
pregnancy period. When the income level of the respondents were cross
tabulated with the medical treatment availed during pregnancy period it was
found that the respondents in the income group below Rs. 1000 were found to
have low intake tetanus injection (87.1%), iron supplement (78.9%) folic acid
supplement (76%) and vitamin supplement (85.7%) when compared to higher
income group of above 5001-10000 (97.4%, 97%, 97.1%, 97.3%
respectively).
This low intake of health supplements on the part of lower income
groups and high intake on the part of higher income groups and the steadily
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progressive increase in all these intakes as income increases show the strong
relationship of the economic factor with intake of these essential items.
Table: 6.5. Religion and medical treatment availed during pregnancy period
during
pregnancy
period
Religion
taken
tetanus
injection
Iron
supplement
Folic acid
supplement
Vitamin
supplement
Got advice
on diet
during
pregnancy
Hindu 98.5% 98.1% 98.1% 98.5% 98%
Muslim 93.3% 90.8% 90.2% 92.7% 88.6%
Christian 87.5% 85.7% 85.7% 87.5% 84.2%
In the developing countries where infectious diseases like cholera,
typhoid, etc are endemic and often occur in endemic forms, it is essential to
immunize against all the diseases by vaccinations, if they have not already
been immunized. It is most important that all pregnant women be immunized
against tetanus, as neo-natal tetanus is one of the common causes of high
prenatal mortality (Mudaliar and Menon, 1998). Usually, pregnant women
will receive two doses of tetanus toxoid. The analysis given in Table 5.6
shows that among Hindus 98.5 per cent of the respondents had taken tetanus
injection and in the case of Muslims and Christians it is 93.3% and 87.5%
respectively. Iron deficiency is another risk for the young mother.
Adolescents who become pregnant within four years of menarche are
physically and psychologically immature and since they are still growing, will
have greater nutritional requirements than adult women. Many girls
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belonging to the poor socio-economic groups are already malnourished. Here
it is observed that there is much religious difference in receiving tetanus
injection, iron supplement, folic acid supplement and vitamin supplement.
Hindus use all of them in largest proportion, followed by Muslims and last by
Christians. The fact that there is consistency in these on all items makes one
to conclude that religion is indeed a factor in availing all these items of ante
natal care.
Thus, our hypothesis that socio cultural factors are related to use of ANC in
the form of the different items prescribed and made available by the PHC
staff is validated.
Medical Check-ups
Table: 6.6. Education and medical check-ups undergone at the time of ANC
Medical Check ups
undergone
Education
Yes No Total
Illiterate 14
63.6%
8
36.4%
22
100.0%
semi literate 80
87.0%
12
13.0%
92
100.0%
High School 158
99.4%
1
.6%
159
100.0%
Higher Secondary 19
100.0%
0
.0%
19
100.0%
Graduate 7
100.0%
0
.0%
7
100.0%
Post Graduate 1
100.0%
0
.0%
1
100.0%
Total 279
93.0%
21
7.0%
300
100.0%
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When we examined the influence of education on the essential medical
checkups required by a pregnant woman during the pre natal period we found
a close relationship between the two as is indicated in the data in Table 6.6.
Periodic medical check-ups include checking of blood pressure, height
and weight, testing of urine and blood and internal check-ups of the uterus
which enables the doctor to detect complications if any during pregnancy and
to overcome any complications that may arise at the time of delivery. In order
to find out to what extent the respondents are aware of the need of medical
check-ups their educational level was cross tabulated with the medical
checkup undergone by them.
The analysis (Table 6.6) showed that 93% of the respondents had
undergone medical check-ups at the time of pregnancy and it was only 7%
who had not. It is also noticed that among the illiterates 63.6% and among the
‘semi-literate 87% had undergone medical check-ups, while it was 100%
among higher secondary, graduate and post graduate respondents. This shows
that the higher the education of respondents, the higher was the medical
checkups.
When the data on the 7.0% non-users of this facility was analysed it
was found that apart from lack of education the other reasons for not going for
medical check-ups as reported by the respondents were financial constraint
(3.7%) and strict seclusion norms (religious) prohibiting women from visiting
health centers (3%) and lack of awareness (0.7%).
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Millions of women in developing countries lack access to adequate
care during pregnancy. Such care can detect and manage existing diseases,
recognize and treat complications early, provide information and counseling
on signs and symptoms of problems, recommend where to seek treatment if
complications arise and help women and their families prepare for child birth.
It may be pointed out that during pregnancy, any woman can develop
serious, life threatening complications that require medical care. Because
there is no reliable way to predict which women will develop these
complications, it is essential that all pregnant women should have access to
high quality obstetric care throughout their pregnancies and especially after
childbirth when most emergency complications arise. It is with this objective
that Government is providing these facilities through the PHCs.
Socio – cultural factors and Place of Antenatal care
Since our society is religious and tradition bound, religious diversity
may influence in receiving pregnancy care. The religious beliefs such as
babies are given by God, may lead them not to avail the ANC facilities, since
they think it is also the responsibility of the Almighty to take care of them. In
our sample a large number of the respondent had approached private clinics
(51.7%) for pregnancy care, 39.7 percent of the respondent had approached
mother and child hospital for pregnancy care and only 7.3 percent of the
respondent had approached primary health centre (PHC) for pregnancy care.
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Table: 6.7. Age and place of Ante-natal care
Place of ANC
Age
PHC Sub-
center
Private
clinic
Mother
and child
hospital
Total
15-19 0
.0%
0
.0%
2
33.3%
4
66.7%
6
100.0%
20-24 3
21.4%
0
.0%
7
50.0%
4
28.6%
14
100.0%
25-29 1
2.0%
0
.0%
38
74.5%
12
23.5%
51
100.0%
30-34 1
1.7%
0
.0%
37
61.7%
22
36.7%
60
100.0%
35-39 9
9.2%
1
1.0%
42
42.9%
46
46.9%
98
100.0%
40-44 6
10.2%
1
1.7%
24
40.7%
28
47.5%
59
100.0%
45-49 2
16.7%
2
16.7%
5
41.7%
3
25.0%
12
100.0%
Total 22
7.3%
4
1.3%
155
51.7%
119
39.7%
300
100.0%
When the percentage distribution of women by place of ante-natal care
was analyzed with their age (Table 6.7), it was found that 51.7% of the
respondents approached private clinics for their ante-natal check-ups while
37.7% respondents approached mother and child hospitals (Govt. hospital) for
their ante-natal check-ups. Age wise analysis showed that majority of the
respondents in the age group of 25 – 29 (74.5%) and 30 – 34 (61.7%)
approached private clinics, while majority of the young age group (66.7%)
approached mother and child hospitals for their ANC.
In private hospitals better facilities are available and the middle age
groups who expected complications during delivery preferred private
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hospitals even though they are expensive. In the rural areas the private
hospitals are small clinics with better facilities and comparatively less
expensive when compared to urban private hospitals. We assumed that this
phenomenon of preference given to private health care centres by the
respondents in their reproductive health care may be because of their better
educational level.
Table: 6.8. Education and place of Antenatal care
Place of ANC
Education
PHC Sub-center Private
clinic
Mother
and child
hospital
Total
Illiterate 1
4.5%
3
13.6%
10
45.5%
8
36.4%
22
100.0%
semi literate 13
14.1%
1
1.1%
39
42.4%
39
42.4%
92
100.0%
High School 8
5.0%
0
.0%
82
51.6%
69
43.4%
159
100.0%
Higher
Secondary
0
.0%
0
.0%
16
84.2%
3
15.8%
19
100.0%
Graduate 0
.0%
0
.0%
7
100.0%
0
.0%
7
100.0%
Post Graduate 0
.0%
0
.0%
1
100.0%
0
.0%
1
100.0%
Total 22
7.3%
4
1.3%
155
51.7%
119
39.7%
300
100.0%
The distribution of mothers by place of antenatal care and education is
shown in table 6.8. The analysis shows that mother and child hospital were
preferred more by the educationally lower level respondents (42.4%) semi
literates and 43.4% high school educated and private hospitals were preferred
by all the graduate and post graduate respondents (100% each). This shows
215
that educational attainment of the respondent is a determinant in their
preference of place of ANC.
The obtained value of chi-square at 15 degrees of freedom is 34.5
against the expected value of 28.26 at p = 0.2. Therefore we can reject the null
hypothesis and conclude that there is significantly high relationship between
the education of the respondent and the place of Ante-natal care.
Table: 6.9. Income and place of Antenatal care
Place of ANC
Income
PHC Sub-
center
Private
clinic
Mother
and child
hospital
Total
Below 1000 9
9.6%
2
2.1%
30
31.9%
53
56.4%
94
100.0%
1001-5000 12
8.9%
1
.7%
69
51.1%
53
39.3%
135
100.0%
5001-10000 1
2.5%
0
.0%
28
70.0%
11
27.5%
40
100.0%
Above 10,000 0
.0%
1
3.2%
28
90.3%
2
6.5%
31
100.0%
Total 22
7.3%
4
1.3%
155
51.7%
119
39.7%
300
100.0%
Income-wise analysis of the data also showed that the highest income
group of respondents approached private hospitals for pregnancy care (90.3%)
while in the low income groups 56.4 percent approached mother and child
hospitals run by the State Government for receiving ANC. There is a clear
income differential seen in choosing the place of antenatal care. The place of
ante natal care received by the respondents showed much difference between
the lowest and highest income groups of respondent also.
216
Table 6.10 shows the result of our analysis of the data in terms of the
religion of our respondents.
Table: 6.10. Religion and place of Antenatal care
Place of ANC
Religion
PHC Sub-
center
Private
clinic
Mother
and child
hospital
Total
Hindu 2
3.0%
1
1.5%
27
40.3%
37
55.2%
67
100.0%
Muslim 14
7.6%
3
1.6%
107
57.8%
61
33.0%
185
100.0%
Christian 6
12.5%
0
.0%
21
43.8%
21
43.8%
48
100.0%
Total 22
7.3%
4
1.3%
155
51.7%
119
39.7%
300
100.0%
Among the Hindus majority (55.2%) of the respondents approach state
run mother and child hospital while majority of the Muslims (57.8%)
approached private clinic for getting ANC. It is also noticed that while 43.8%
of the Christian respondents approached private clinics an equal number of
them approached mother and Child hospitals as well. We can conclude from
the data that there is a relationship between religion and place of ante natal
care.
217
Socio-Cultural factors in natal care
An important component of health care services of mothers and babies
is the provision of proper medical care at the time of delivery. This will
reduce the risk of complications and infections that can seriously affect the
health of the mother and the newborn. The major factor that determines natal
health includes the place of delivery, type of delivery and the type of care
received by the respondents while in hospital. Institutional delivery in the
presence of trained medical practitioners is considered to be the best mode of
childbirth as far as the post natal care of the respondent is concerned. Hence
the place of delivery of the respondents was analyzed in order to find out the
factors in post natal health of the respondents.
Our analysis of the data showed that 44.7 percent of the childbirths had
taken place in private hospitals, 41 percent in Government hospitals, 8.3
percent at home and 6 percent at primary health centre. Respondents who
preferred home to hospital gave reasons such as kin support, familiarity,
tradition as well as their feeling that birth is a normal phenomenon that does
not need an institutional setting.
Type of delivery plays an important role as far as reproductive health
of mother is concerned. In this study majority (86%) of the respondents had
normal delivery, whereas only 13.7 percent of the deliveries were caesarian.
218
Age and Place of delivery
In this section the socio-cultural factors and place of delivery of the
respondents were analyzed. The present age of the respondents and place of
delivery is given in Table 6.11.
Table: 6.11. Present age and place of delivery of the last child
Place of
delivery
Age
PHC Private
hospital
Govt.
hospital Home Total
15-19 0
.0%
2
33.3%
4
66.7%
0
.0%
6
100.0%
20-24 2
14.3%
8
57.1%
4
28.6%
0
.0%
14
100.0%
25-29 1
2.0%
37
72.5%
13
25.5%
0
.0%
51
100.0%
30-34 1
1.7%
38
63.3%
21
35.0%
0
.0%
60
100.0%
35-39 11
11.2%
39
39.8%
43
43.9%
5
5.1%
98
100.0%
40-44 3
5.1%
8
13.6%
35
59.3%
13
22.0%
59
100.0%
Above 45 0
.0%
2
16.7%
3
25.0%
7
58.3%
12
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
The table reveals that 44.7 percent of the respondent had approached
private hospital for delivery and 41.0 percent had approached govt. hospitals.
It was observed from the table that while 33.3 percent of the adolescent
mothers preferred private hospitals, the corresponding percentage for
government hospitals was 66.7 percent. Table also showed that the
respondents in the age groups 20-24, 25-29 and 30-34 approached private
hospitals for delivering their children (57.1%, 72.5% and 63.3% respectively).
219
The respondents in the higher age group of 35-39 (43.9%), 40-44 (59.3%)
preferred govt. hospitals for delivering their children. The proportion of home
deliveries at home is highest for higher age group of above 45 years (58.3%).
This is because at the time of their last delivery, home deliveries were more
common than at later times.
This table shows a positive relation between the age of the respondent
and the place of delivery. The very young age group and the older age group
who are considered to be the risk category preferred govt. hospitals because
govt. hospitals with experienced and highly qualified doctors and nurses were
assumed to be more capable of handling delivery complications than private
hospitals.
Table: 6.12. Age at marriage and place of delivery
Place of
delivery
Age at
marriage
PHC Private
Hospital
Govt.
Hospital Home Total
Below 15 2
3.2%
16
25.8%
25
40.3%
19
30.6%
62
100.0%
16-19 10
7.6%
72
55.0%
44
33.6%
5
3.8%
131
100.0%
20-24 5
5.1%
40
40.4%
53
53.5%
1
1.0%
99
100.0%
25 and above 1
12.5%
6
75.0%
1
12.5%
0
.0%
8
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
The percentage distribution of respondents by place of delivery and
age at marriage is shown in Table 6.12. A varying trend is seen with age at
marriage and institutional deliveries (both Government and Private hospitals).
220
Proportion of home deliveries decreased with increase in age at marriage. So
higher age at marriage had influenced women to prefer institutional
deliveries. This is quite in conformity with Table 6.12 where those belonging
to older generation had indicated that they were mostly delivered at home
when home delivery was common. When it comes to age at the time of
delivery we find that those who were married at or after age 25 preferred
private hospitals because they anticipated their delivery to complicated and
preferred private hospitals (75%) where they expected more careful attention
to delivery cases. Also, among those who were married at or before 15 years
of age 30.6% had home deliveries because they expected their deliveries to be
normal. The relationship between education and place of delivery is given in
Table 6.13.
Table: 6.13. Education of respondents and place of delivery
Place of delivery
Education PHC
Private
Hospital
Govt.
Hospital Home Total
Illiterate 0
.0%
1
4.5%
8
36.4%
13
59.1%
22
100.0%
Semi literate 8
8.7%
27
29.3%
45
48.9%
12
13.0%
92
100.0%
High School 10
6.3%
82
51.6%
67
42.1%
0
.0%
159
100.0%
Higher Secondary 0
.0%
16
84.2%
3
15.8%
0
.0%
19
100.0%
Graduate 0
.0%
7
100.0%
0
.0%
0
.0%
7
100.0%
Post Graduate 0
.0%
1
100.0%
0
.0%
0
.0%
1
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
221
Education of respondents has been found to play a major in their
preference for place of delivery. The analysis showed that while majority
(59.1%) of the illiterate delivered their child at home, all the graduate and
post graduate respondents (100% each) preferred private hospitals. 84.2% of
the higher secondary educated women also had their delivery in private
hospitals. It is also noticed that a large section of the semi literate (48.9%) and
high school educated (42.1%) preferred govt. hospitals. This may be due to
the fact that as the educational level increases their economic level also
increases. So they can afford private hospitals for delivery. It can be said that
women’s education has a positive influence in choosing the place of delivery,
as the level of education increases, preference for institutional delivery also
increases.
In Table 6.14 we give the analysis of data on the relationship between
husband’s education and place of delivery of wife (our respondents).
222
Table: 6.14. Education of husband and place of delivery
Place of
delivery
Education of
Husband
PHC Private
Hospital
Govt.
Hospital Home Total
Illiterate 0
.0%
0
.0%
6
60.0%
4
40.0%
10
100.0%
Semi Literate 9
6.2%
48
32.9%
68
46.6%
21
14.4%
146
100.0%
High School 8
6.7%
65
54.6%
46
38.7%
0
.0%
119
100.0%
Higher
Secondary
1
5.3%
15
78.9%
3
15.8%
0
.0%
19
100.0%
Graduate 0
.0%
6
100.0%
0
.0%
0
.0%
6
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
Since our society is male dominated, most of the decisions in the
family are taken by the husband. So it is relevant to examine the husband’s
educational attainment, along with the wife’s education, which may influence
the choice of the place of delivery of their wives. Hence the table on the
education of husband and the place of delivery was analyzed. The analysis
brought to light the fact that in the case of the husbands who were illiterate
and semi-illiterate the delivery of their wives had taken place at govt.
hospitals (60% and 46.6% respectively). It was also noticed that among the
illiterate husbands, 40 percent of the wife’s delivery had taken place at home.
It is clear from the table that as the education of husbands increased those
who prefer institutional deliveries also increased. Selection of private
hospitals for the delivery of their wives was found more among the husbands
223
whose educational qualifications were high. These results may be due to the
reason that, generally higher educated husbands usually occupy a higher
socio-economic status in the society and this led them to prefer private
hospitals as they could afford the comparatively higher cost of private in
Table 6.15 gives the table on occupation of the respondents and their places of
delivery.
Table: 6.15. Occupation and place of delivery
Place of
delivery
Occupation
PHC Private
Hospital
Govt.
Hospital Home Total
Unemployed 12
5.8%
101
48.6%
73
35.1%
22
10.6%
208
100.0%
Blue collar 3
10.3%
6
20.7%
20
69.0%
0
.0%
29
100.0%
White collar 0
.0%
11
84.6%
2
15.4%
0
.0%
13
100.0%
Business 2
18.2%
6
54.5%
3
27.3%
0
.0%
11
100.0%
Professional 0
.0%
2
100.0%
0
.0%
0
.0%
2
100.0%
Unorganized
sector
1
2.7%
8
21.6%
25
67.6%
3
8.1%
37
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
Occupation of the respondents has a major influence on their choice of
institutions for their delivery. The relation between the occupation of
respondent and their place of delivery showed that 48.6 percent of the
unemployed respondents preferred private hospital, where as 69 percent of the
blue collar respondents preferred government hospitals. It was also noticed
224
that respondents who were employed in white collar, business and
professional occupations (84.6%, 54.5% and 100%) preferred or selected
private hospitals over govt. hospitals. It may also be noted that all those who
had their deliveries at home were unemployed or working in the unorganized
sector. So it can be said that women’s better occupational status had a
positive influence on choosing the place of delivery.
In Table 6.16 the relationship between religion and place of delivery is given.
Table: 6.16. Religion and place of delivery
Place of
delivery
Religion
PHC Private
Hospital
Govt.
Hospital Home Total
Hindu 2
3.0%
27
40.3%
38
56.7%
0
.0%
67
100.0%
Muslims 10
5.4%
91
49.2%
61
33.0%
23
12.4%
185
100.0%
Christian 6
12.5%
16
33.3%
24
50.0%
2
4.2%
48
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
When the place of delivery was analyzed on the basis of their religion
it was found that delivery of babies at home was more among Muslims
(12.4%) when compared to Christians (4.2%). None of the Hindus had
delivery at home. Among the Hindus 56.7 percent approached govt. hospitals
while 50 percent of the Christians approached govt. hospitals. This analysis
brought to light the fact that among the respondents who had delivered their
child at home a vast majority belong to the Muslim community (92%) which
225
shows their low awareness regarding maternity and child health. Chi square
test also showed strong relationship between religion and place of delivery.
Table: 6.17. Income and place of delivery
Place of
delivery
Family Income
PHC Private
Hospital
Govt.
Hospital Home Total
Below 1000 9
9.6%
18
19.1%
56
59.6%
11
11.7%
94
100.0%
1001-5000 9
6.7%
61
45.2%
54
40.0%
11
8.1%
135
100.0%
5001-10000 0
.0%
28
70.0%
10
25.0%
2
5.0%
40
100.0%
Above 10,000 0
.0%
27
87.1%
3
9.7%
1
3.2%
31
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
It is observed from Table 6.17 that 57.6 percent of below Rs.1000
income group approached govt. hospitals for delivery, whereas 70 percent of
the Rs.5001-10000 and 87.1% of the above Rs.10,000 income group preferred
private hospitals. Delivery of children at home was found to be more among
the low income group of below Rs.1000. This analysis shows that as the
income increases preference for private hospitals also increases. This may be
due to the better infrastructure facility available at private hospitals which can
be afforded by the high income group. Generally higher income groups
usually occupy higher socio-economic status in the society and this leads
them to prefer private institutions for delivery of children.
226
From these discussions (Tables 6.16 to 6.17) it can be concluded that
education, age, age at marriage, occupation and income of respondent have
strong influence on the selection of their place of delivery.
5.2.2. Place of Delivery and Type of Delivery
In this section we consider the place of delivery and type of delivery of
our sample women. The type of delivery includes both normal delivery and
caesarean delivery.
In our sample among the total deliveries 86.0 percent were normal. In
some cases, there may be complications during delivery and these
complications would tend physicians to choose caesarian delivery for the
safety of both the mother and child. So in the present section, the fact that we
had 13.7 percent caesarian deliveries warrants an analysis of these cases.
International statistics indicate that caesarean cases in hospital
deliveries varied from 32 percent in Brazil to about 7 percent in
Czechoslovakia in the 1980. (Notzom, 1990). Many studies had reported that
place of delivery had some influence on the type of delivery. For example, the
incidence of caesarian section deliveries is reported to be higher in private
health institutions when compared to that in government hospitals (Kannan et
al. 1991). So it is relevant to relate the place of delivery with the type of
delivery. Tables 6.18 give details about the place and type of delivery.
227
Table: 6.18. Place of delivery and type of delivery
Place of
delivery
Type of delivery
PHC Private
Hospital
Govt.
Hospital Home Total
Normal 18
7.0%
108
41.9%
107
41.5%
25
9.7%
258
100.0%
Caesarian 0
.0%
26
61.9%
16
38.1%
0
.0%
42
100.0%
Total 18
6.0%
134
44.7%
123
41.0%
25
8.3%
300
100.0%
Table 6.18 shows that private hospitals showed the highest percentage
of caesarian delivery (61.9%) whereas the corresponding percentage for
government hospitals is 38.1 percent. This illustrates the higher chance of
caesarian deliveries in private hospitals. Also this result supports the findings
of another study conducted in Kerala using NFHS data where the same trend
was noticed. (Padmadas, 2000). This high proportion of caesarean deliveries
in private hospitals could be due to economic benefit to the hospital and to
avoid possible complications during delivery.
In institutional deliveries, doctors, nurses and others take care of the
risks during delivery. But deliveries at home are mostly attended by an Aya,
sometimes qualified, sometimes not. In our study group, 8.3 percent of the
total deliveries took place at home and they were normal deliveries. So it is
relevant to relate the place of delivery with the type of delivery as the place of
delivery had some effect on the type of delivery.
228
Type of delivery and health problems related to childbirth
Table: 6.19. Type of delivery and health complications
During pregnancy After delivery Health problems
Type of delivery Yes No Yes No
Normal 43% 57% 33.5% 66.5%
Caesarian 72% 28% 61.5% 38.5%
Type of delivery (Normal and Caesarian delivery) may generally relate
to the health problems of women during their pregnancy, during delivery and
after delivery. The type of delivery may also have some effect on the
reproductive health problems after delivery. Here in this section, we examine
the type of delivery and reproductive health problems in antenatal, natal and
post–natal periods. The analysis indicates that there is slight variation in the
proportion of caesarian section delivery with the reproductive health problems
during post-natal period.
Table 6.19 shows the percentage distribution of women by their type of
delivery by the reproductive health problems they had experienced during
pre-natal, natal and post-natal periods. During the pre-natal period, there is
variation between the types of delivery and health problems. It is seen that
among the women, who had experienced some health problem during
delivery, about 35 percent had caesarian section delivery. The Table shows
229
that among the women, who had experienced some health problem after
delivery; about 61.5 percent were having caesarian section delivery. At the
same time nearly 38.5 percent of women had caesarian section delivery and
had no problem at the time of delivery.
So we can conclude that the type of delivery is influenced by the
reproductive health problem during pregnancy, delivery and after delivery.
That is, the problems present at the time of pregnancy and delivery are likely
to increase the chance of caesarian section delivery very much. And also a
comparatively high percentage of reproductive health problems are observed
during the post–natal period for those who had caesarian section delivery.
Type of delivery and Morbidity
There is a general belief that type of delivery has much effect on the
health problems of a woman, especially, as far as caesarian section delivery is
concerned. The reason behind such a belief is that normal delivery is a natural
process and it is not harmful to the body. But caesarian section delivery is
artificially done and this may have some impact on the health of the mother.
In our earlier section it was seen that those who had experienced some
reproductive health problem during pregnancy are more prone to caesarian
type delivery. So in this section let us examine whether this type of deliveries
has any future effect in the form of reproductive morbidity condition with
which we are concerned.
230
Table: 6.20. Percentage distribution of mothers by gynecological
morbidity symptoms and type of delivery
Gynecological morbidity
Type of delivery Yes No
Normal 52.8% 47.2%
Caesarian 73% 27%
The table upholds the general belief that caesarian delivery is
associated with problems of morbidity. While only 52.8% of the normal
delivery cases had gynecological problems, the percentage of those with such
problems in the caesarian cases was 73.
Health care after delivery
In Kerala after delivery, there are mainly three form of post-natal care
such as traditional, Ayurvedic and Allopathic. The study revealed that 94.3
percent of respondents had undergone one or the other form of post-natal
care. When the duration of this care was analyzed it was found that 52.7
percent of respondents had undergone health treatment only for one month,
while 41.3 percent had undergone health treatment for three months. The
health treatment included allopathic and Ayurvedic medicines, special diet,
food, oil massage, completes body rest etc. For majority of the respondents
this care was provided by their mothers (71.3%). A vast majority of the
respondents (96%) used both Ayurvedic and Allopathic health improving
medicines.
231
Since post natal care is very important in reproductive health, we
examined this data to find any socio-cultural variations in this. The findings
are given in Table 6.21.
Table: 6.21. Religion and traditional post-natal care
Utilization of
Post natal care
Religion
Yes No Total
Hindu 64
95.5%
3
4.5%
67
100.0%
Muslim 173
93.5%
12
6.5%
185
100.0%
Christian 46
95.8%
2
4.2%
48
100.0%
Total 283
94.3%
17
5.7%
300
100.0%
The relation between religion and post natal care showed that 95.5
percent of Hindus, 93.5 percent of Muslims and 95.8 percent of Christians
had undergone post natal care at home. This analysis shows that irrespective
of religion all respondents were undergoing traditional post-natal care which
included medicine, oil bath as well as special diet at home after delivery.
Hence, there is no difference between the different religions in the matter of
post natal care.
232
Conclusion
In this chapter, the researcher has examined the socio-cultural
dimensions of reproductive health care in terms of the following variables:
ante natal care – determinants, components and place, ante natal medical
checkup, place and type of delivery, health problems associated with child
birth, type of delivery and morbidity and health care after delivery.
Our major hypothesis in this area is that there is significant relationship
between socio- cultural background and behavior relating to reproductive
health care.
This has been found true of each component of socio-cultural variables
and reproductive health variables at the pre natal, natal and post natal stages.
Each of these relationships has been clearly proved as is shown in the analysis
of the data in this chapter. These are summarized below, When the number of
ante natal care (ANC) visits of the respondents was cross tabulated with their
religion it was found that Hindu respondents had taken ANC visits more
(79.1%) compared to other religious groups.
The relation between educational attainment and the number of ANC
showed that monthly visits were higher among respondents having education
at higher secondary, graduate and post-graduate levels (100% each).
Income-wise analysis also showed that respondents in the high income
group of above Rs.10, 000 were more when compared to the low income
233
group. When the availing of medical treatment during pregnancy period was
cross tabulated with their income it was found that the respondents in the
below Rs.1000 income group had availed medical treatment lesser than the
higher income group of above Rs.5001-10,000.
The religion-wise analysis of medical treatment availed during
pregnancy period showed that this was higher among Hindus and lower
among Christians.
The analysis also brought to light the fact that more respondents having
higher education had undergone medical checkups during their pregnancy
period than those who were having lower education.
The relation between age and place of ANC showed that majority of
the respondents in the middle age group of 25 – 29 (74.5%) and 30-34
(61.7%) approached private clinics while majority of the very young age
group of 15-19 (66.7%) approached mother and child hospitals run by the
state govt. for their ANC.
When the data on place of ANC was cross tabulated with educational
attainment it was found that mother and child hospital were preferred more by
the educationally lower level respondents (semi-literate 42.4% and high
school educated 43.4%) whereas private hospitals were preferred by all the
graduate and post graduate respondents (100% each).
234
The relation between income and place of ANC showed that the
highest income group respondents approached private hospitals for pregnancy
care (90.3%) while the low income groups (56.4%) approached mother and
child hospitals run by the state govt. for receiving ANC.
The relation between religion and place of ANC showed that a large
section of Muslims (57.8%) approached private hospitals, while 55.2% of the
Hindus opted mother and child hospitals while Christians preferred both these
type of hospitals equally.
The above analysis showed that the socio-economic and cultural
variables like age, education, income and religion play a significant role in
determining the attitude towards pregnancy check-ups, selection of ANC
centers and treatment availed during pregnancy period. When the place of
delivery was cross tabulated with current age it was found that the proportion
of delivery at home was highest for higher age group of above 45 years
(58.3%).
The relation between age at marriage and the place of their delivery
showed that respondents having higher age at marriage had preferred
institutional deliveries when compared to the respondents in the lower age at
marriage.
When the place of delivery was cross tabulated with educational
attainment it was found that respondents having higher education had
preferred institutional deliveries than the illiterates or semi literates. The
235
analysis also highlighted the fact that the education of the respondent’s
husbands also had influenced the preference for institutional delivery.
Respondents whose husbands were illiterates (40%) and semi literate (14.4%)
had preferred delivery at home when compared to the other educated
categories.
The type of occupation and the place of delivery showed that
respondents who were employed in white collar and professional occupations
(84.6%, and 100% respectively) preferred private hospitals than govt.
hospitals.
When the place of delivery was cross tabulated with religion it was
found that a vast majority of the Muslim respondents (92%) had delivered
their child at home.
When income and place of delivery were cross tabulated it was found
that private hospitals were preferred more by the respondents in the high
income group whereas low income group preferred delivery at home or at
mother and child hospital.
When the place of delivery was cross tabulated with the type of
delivery it was found that (61.9%) had undertaken caesarian type deliveries in
private hospitals when compared to the govt. hospitals.
The relation between the type of delivery and health problems
associated with child birth brought to light the fact that vast majority of the
236
respondents (72%) who had health problems during pregnancy had undergone
caesarian type delivery and 61.5% of the respondents who had undergone
caesarian type deliveries had health problems after delivery.
When the gynecological morbidity was cross tabulated with type of
delivery it was found that more gynecological problems were found among
the respondents who had undergone caesarian type deliveries. Almost all the
respondents had taken health improving treatments after delivery which
included Ayurvedic and Allopathic medicines, oil baths as well as complete
body rest.
In the relation between religion and traditional post natal care it was
found that irrespective of religion vast majority of the respondents from all
religions utilized post natal care.
With regard to the health care practices after delivery it can be
concluded that socio-cultural variables like age at marriage, education,
occupation, religion, income and type of delivery have positive relation with
the place and type of delivery, health problems related to child birth,
gynecological morbidity and health care at home after delivery.
In the light of these findings we can conclude that the hypothesis that
socio cultural background and reproductive health care behaviour are
significantly related.